Health inspection·January 25, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the failed to prevent a resident from developing pressure injuries and failed to identify pressure injuries prior to becoming stage 3, and unstageable for 1 of 3 residents (R1) reviewed for pressure injuries in the sample of 3. Residents Affected - Few The findings include: R1's census report shows she was admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses include obesity, hemiplegia and hemiparesis following a cerebral infarction affecting left non dominant side. The facility assessment of 11/30/23 documents R1 is a moderate risk for developing pressure sores due to being chairfast and very limited mobility. The 10/27/23 care plan documents R1 is at risk for impaired skin integrity related to advanced age, decreased mobility, diabetes, and a history of pressure injuries. R1's December 2023 TAR (Treatment Administration Record) shows an order upon admission to notify the MD with any change in skin/document every night shift for admission. The wound rounds report shows an unstageable wound to the right heel identified on 11/28/23. R1's care plan documents a blister to the right heel, and on 12/5/23 the blister increased in size and measured 5 cm (length) by 5.2 cm (width) and was full of fluid and dark dry surrounding edges. The notes show podiatry was managing the heel wound. R1's 11/13/23 podiatry progress notes show she had no pressure wounds or concerns with her heels. The 12/8/23 progress note shows she had developed wounds to her bottom and now to her right heel. The exam shows a 4 cm by 3 cm fluid filled pressure blister located to the posterior right heel. The 12/27/23 progress notes show the wound to be 4.5 cm x 3.5 cm and 0.1 cm (depth). The plan of care shows R1 was recommended for the initiation of local wound care and follow-up with the wound center. R1's 12/4/23 progress notes for skin/wound note shows V6 LPN/ wounds (Licensed Practical Nurse) documented a stage 3 pressure wound identified on the left buttock. The wound measured 2.2 cm wide by 1.2 cm in depth and 0.1 cm. V6 noted R1 had a decline in mobility and spending more time in bed related to a recent diagnosis of Covid 19. R1's initial physician wound evaluation and management summary of 12/7/23 shows V7 (Wound physician) assessed the left medial buttock to have a stage 3 pressure wound measuring 1.0 cm (length) by 0.7 cm (width) and 0.3 cm (depth). On 1/24/24 at 2:15 PM, V6 stated she initially identified the buttock wound at a stage 3. It had (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145278 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Sterling,the 105 East 23rd Street Sterling, IL 61081 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)